Brain Death and End of Life Christian Sonnier MD LSUFP Alexandria 62515 Learning objectives Define brain death coma and persistent vegetative state Discuss management of each of the above Breaking bad news ID: 434313
Download Presentation The PPT/PDF document "ICU Lecture #6" is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
Slide1
ICU Lecture #6Brain Death and End of Life
Christian Sonnier MD
LSU-FP Alexandria
6/25/15Slide2
Learning objectives
Define brain death, coma and persistent vegetative state
Discuss management of each of the above
Breaking bad news
Discuss end of life careSlide3
Brain Death
Definition:
Total and irreversible cessation of all spontaneous and reflexive brain functions
Determined clinically by
Positive coma
Absence of all brain stem reflexes
apnea
Ancillary testing is not required but does include
Cerebral blood flow studySlide4
Brain Death
Preparation for Brain Death Assessment
Notify LOPA
Involve nurse and appropriate religious officials or medical ethics personnel
Discuss with family
d/c sedation and paralytics
Confirm the following
Known and irreversible cause
Clinical and radiological evidence of CNS catastrophe
If associated with cardiac arrest re-examine q6hrs
Insure no significant electrolyte or acid base imbalance is present
r/o drugs and alcohol intoxicationSlide5
Brain Death
Clinical findings for brain death:
Coma: no eye opening to command, no verbal response, no purposeful movement. No withdrawal to pain
Can not confirm brain death in presence of severe metabolic derangements.
Absence of brain stem reflexes
Pupils fixed and unresponsive
No ocular movements
No
oculovestibular
reflex (cold water in ears with
nystagmus
)
No corneal reflex
No grimace or w/d from pain
Absent pharyngeal and tracheal reflexes such as gag/coughSlide6
Brain Death
Clinical findings of brain death
Apnea test
Normal body temperature and adjust vent for
abg
that is within following (
ph
7.35-7.45) (PaCO2 35-45)
Pre-oxygenate with FIO2 until PaO2 is over 200
1) disconnect from vent and provide 100% oxygen
2) observe for
resp
movements for 8 minutes
Cyanosis,
sbp
under 90, significant O2 desaturation or arrhythmia is positive for apnea and brain death and stop test
3) re-check
abg
and reconnect to vent
If
abg
meets following then consider positive
PaCO2 over 60 or increased by more than 20 from first
abgSlide7
Brain Death
If all of the above are documented and observed then 2 licensed physicians are required to agree in order to w/d from life support.Slide8Slide9Slide10
Cerebral blood flow study
http://
www.nucmedresource.com/brain-death-scan.html
This was the website I was directed to when I spoke to the radiologist about the results. Slide11
Coma
Definition:
Unarousable
unresponsiveness
Etiology/pathophysiology
Can be result of any of the following
Diffuse, bilateral cerebral damage
Unilateral cerebral damage causing a midline shift or compression of contralateral hemisphere
Supratentorial
mass lesion causing herniation
Posterior fossa mass causing brainstem compression
Toxic or metabolic issues including overdoses
Status
epilepticus
Apparent/
pseudocoma
(locked-in, hysterical
rxn
ect
)
s/p cardiac arrest, stroke, ICH are the most commonSlide12
Coma
Bedside
eval
:
Through evaluation of cranial nerves, complete
neuro
exam, history, labs, imaging, and full physical exam
Motor responsesSlide13
Coma
Bed side
eval
Response to pain
Eye opening
Pupil examSlide14
Coma
Bedside exam:
Ocular motility
Ocular reflexesSlide15
Coma
Bed side exam
Oculovestibular
reflex
GCSSlide16
Coma
Conditions mistaken for coma
Locked in syndrome
Focal injury to base of pons usually embolic occlusion to basilar artery
Can be mimicked by upper spinal cord lesion, motor neuron disease,
parkinsons
ect
Akinetic
mutism
Injury to pre-frontal or pre-motor areas
Will follow with eyes but does not obey or
initate
other motor commands
Tone, reflexes usually remain intact (including cold caloric and postural reflexes)
Psychogenic unresponsiveness
Catatonia. This is a psych issueSlide17
Coma
Diagnosis
Work up for infection, metabolic
abnl
, seizures, overdoses, surgical complications
Cbc
,
cmp
,
abg
, mag,
phos
, LP, cultures, urine studies, possible LP,
ct
head,
mri
head,
cta
head and neck,
eeg
, drug screen, thyroid and hormone function testsSlide18
Coma
Management
Support ABC’s
Support hemodynamics
Treat any discovered underlying diseasesSlide19
Coma
Prognosis
Coma is a transitional state between acute injury and PVS or brain death…basically can go either way (recovery to death)
Use APACHE II, GCS, and FOUR points scale as well as clinical judgment to determine prognosisSlide20
FOUR Points score
Eye
response
4
= eyelids open or opened, tracking, or blinking to command
3 = eyelids open but not tracking
2 = eyelids closed but open to loud voice
1 = eyelids closed but open to pain
0 = eyelids remain closed with pain
Motor response
4 = thumbs-up, fist, or peace sign
3 = localizing to pain
2 = flexion response to pain
1 = extension response to pain
0 = no response to pain or generalized myoclonus status
Brainstem reflexes
4 = pupil and corneal reflexes present
3 = one pupil wide and fixed
2 = pupil or corneal reflexes absent
1 = pupil and corneal reflexes absent
0 = absent pupil, corneal, and cough reflex
Respiration
4 = not intubated, regular breathing pattern
3 = not intubated,
Cheyne
-Stokes breathing pattern
2 = not intubated, irregular breathing
1 = breathes above ventilator rate
0 = breathes at ventilator rate or apnea Slide21Slide22Slide23Slide24
Breaking bad news
There are many ways to go about this however below is the model I used with this patient’s family and it seemed to work well.
SPIKESSlide25
Breaking Bad News
SETTING UP the interview
Assessing
patient
’
s and family’s
PERCEPTION
Obtaining the
patient
’
s and family’s INVITATION
Giving KNOWLEDGE and information
Addressing the
patient
’
s and family’s
EMOTIONS
STRATEGY and SUMMARY Slide26
Breaking Bad News
Setting up the interview
Determine who needs to be there. Ask the family who needs to be there.
In our case it was children, nurse, myself +/- attending
Set a time: should not be rushed let the family tell you when they are ready
Prepare, prepare, prepare: you want to know everything and anticipate questions
Must be in private place.Slide27
Breaking Bad News
Assessing family/patient PRECEPTION
Gather before you Give
Patient
’
s
knowledge, expectations and hopes
What do they understand about the situation? Unrealistic expectations?
What is their state of mind?
Hopes
?
Opportunity to correct misinformation and tailor your
information
this is the time to let them speak first, always remember if the family has
somethi
ng
to say
…stop talkingSlide28
Breaking Bad News
Obtaining patient’s/family’s INVITATION to speak
Again you always want to ask if they are ready to talk before you start speaking and allow them to change their minds as much as they want
How much do they want to know? Very important.
Answer questions asked, always ask how much detail/ information do they want.Slide29
Breaking Bad News
Giving KNOWLEDGE
Warning
shot
Use simple language, no jargon,
Vocabulary and comprehension of patient
Small chunks, avoid detail unless requested
Pause, allow information to sink in
Wait for response before continuing
Check understanding
Check impactSlide30
Breaking Bad News
Addressing the
patient
’
s
EMOTIONS with empathic responses
Shock, isolation, grief
Silence, disbelief, crying, denial, anger
Observe
patient
’
s
responses and identify emotions
Offer empathic
responses
R
emember
empathy is: The
capacity to recognise emotions that are being felt by another
person you do not have to “feel” these emotions with them.
Slide31
How to express emphathy
An indication to the patient that you recognise what they are feeling (and why)
Verbal and Non verbal
Often associated with the impact of the news rather than the understanding.
I see that…. I appreciate …..
Wait for response
ClarifySlide32
Breaking Bad News
Step 6: S – STRATEGY and SUMMARY
Are they ready?
Involve the patient in the decision making
Check understanding
Clarify patient
’
s goals
Summarise
Contract for
future
I
mportant
to allow the patient’s family to make the decision. Emphasize to them that they are in control and you are here to advise them and implement the actions for them. Important to emphasize that they are not locked into any decision. Slide33
End of Life Care
Pt
in the last days/hours often have severe and unrelieved suffering
Physical, emotional, social
Recognizing this kind of patient is important and should prompt a shift from active disease management to comfort care
Different cultures have different definitions of a “good death” and is entirely personal
Important to remind patient and family that there is no wrong answersSlide34
End of Life Care
Place of death
Home (+/- hospice)
vs
NH
vs
inpatient hospice
vs
inpatient floor
vs
ICU
Discuss this with the patient and family
Consider burden to patient, family, financial, providers (last one matters the least)
Consider fears associated with eachSlide35
End of Life Care
Estimating short term prognosis
Diagnosing dying
Very difficult however certain clinical signs are suggestive of death within daysSlide36Slide37
End of Life Care
Honoring preferences for end of life care
Discuss DNR/DNI (code status with every patient both outpatient and inpatient…should be standard operating procedure when admitting patient)
Discuss venue of care and make every effort to respect these wishes
Patient dying in the ICU
ICU’s are designed to deliver state of the art life prolonging care however they can do a good job at palliative care
ICU’s have strict visitation hours and offer limited family privacy…always consider stepping down patient to offer more privacySlide38
End of Life Care
Physiologic changes and
sx
This is not an all inclusive list but the active process of dying frequently involves
Weakness, fatigue, functional decline
Decreases oral intake
Hypotension
Neurological derangements
Upper airway secretions “death-rattle”
Loss of sphincter tone
Inability to close or open eyesSlide39
End of Life Care
Palliative care
There is an entire emerging specialty devoted to this.
Goals are comfort careSlide40
End of Life Care
When death occurs
MD and or nurse needed to pronounce death and complete death certificate
Assess the situation and have family step out of room if appropriate
Assess for respirations, pulse, response to pain and stimuli
Coordinate with patient’s family for post-mortem servicesSlide41
End of Life Care
Resources
Beacon project
Hospital Chaplain or other religious services
Uptodate.com
: Palliative care: the last hours and days of lifeSlide42
References:
SPIKES – A Six-Step Protocol for Delivering Bad
News
WF
Baile
, R
Buckman
et al.
The Oncologist 2000;5:302-
311
Marino’s Blue ICU bookSlide43
References
http://
www.nucmedresource.com/brain-death-scan.html
Pocket ICU
pg
19-1-19.4
NEJM, 2001:344;1215
Uptodate.com